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MEASLES

PGI KRISTEL MAGNE ZARASPE

General Data
D.A

21 years old
Male
Single

Catholic
Tabangao, Ambulong, Batangas City
Admitted on December 15, 2013

Chief Complaint
Rashes

History of Present Illness


1 week PTA
on and off undocumented fever
Cough non productive, whitish phlegm
Colds
No consult done
Self medicate with Paracetamol 500mg/tab every 4 hours and
Ibuprofen

5 days PTA
Loss of appetite
Post prandial pain
Throat pain
Generalized body weakness
No consult done
Continue self medication

2 days PTA
Rashes, pruritic
Cough, productive, yellowish phlegm
Few hours PTA
Rashes progressively spread all over his body
Difficulty of breathing

Past Medical History


Unrecalled course of immunization

(-) surgery, accidents and blood tranfusion


(-) heredofamilial diseases

Family History
(-) HTN, DM

Personal and Social History


Occasional alcoholic drinker

3-4 sticks/day

Review of System
General: (-) weight loss, (-) weight gain, (-)chill, (-)

fatigue, (-) night sweats


Skin: (-) color change, (-) soreness, (-) scaling
Head and Neck: (-) headache, (-) stiffness, (-)trauma
Eyes: (-) corrective lenses, (-)pain, (-) blurring of
vision, (-) dryness

Ears: (-) hearing loss, (-) pain, (-) tinnutus

Nose: (-) nasal discharges


Mouth: (-) bleeding gums, (-) hoarseness, (-) pain,

(-) dryness
Respiratory: (-) cough, (-) chest, (-) dyspnea
Cardiac: (-) orthopnea, (-) PND, (-) palpitation
Nervous: (-)dizziness, (-) seizures
Extremities: (-) pain, (-) weakness, (-) tenderness,
(-) cramps

Physical Examination
General Survey: The patient is conscious, coherent,

ambulatory, weak looking and not in cardiorespiratory distress.


Vital signs:
BP: 90/60 mmHg
Cardiac rate: 83beats/minute
Respiratory Rate: 19 cycles/minute
Temperature: 38.20C

Skin: brown, warm, moist with good skin turgor , (+)

maculopapular rashes all over


HEENT: conjunctival injection, hyperemic sclera, no
sunken eyeball, dry lips, (+)nasal watery discharge,
moist buccal mucosa, no tonsillopharyngeal
congestion, no cervicolymphadenopathy, no neck
vein engorgement, no anterior neck mass, no neck
bruit

CHEST/LUNGS: symmetrical chest expansion, no

lagging, no retractions, (+) crackles on midbasal lung


fields bilateral
HEART: Adynamic precordium, point of maximal

impulse is located at the 5th ICS left midclavicular


line, normal rate and regular rhythm, no murmurs

ABDOMEN: flabby abdomen, normoactive bowel

sounds , soft, non-tender on light and deep palpation


EXTREMITIES: grossly normal extremities, no

cyanosis and edema with full and equal pulses on


brachial and radial.
DRE: not done

Neurological Exam
Cerebral Function: awake, alert, oriented to time,

person and place, with intact remote, recent


memory,can do simple calculations, with good
judgement
Cerebellar Function: able to perform finger to nose
test, alternating supination and pronation.
Cranial Nerves: Intact

Motor Function: no muscle atrophy, muscle strength

is 5/5 on both upper and lower extremities, no


tremors noted
Sensory Function: reacts to pain, touch, position and
vibration sense
Reflexes: (+) deep tendon reflexes

Admitting Impression
Measles

Community Acquired Pneumonia

Admission: ER
IVF: D5LR 1L x 40 gtts/ min

Diet: Diet as Tolerated; Increased oral fluid intake


Diagnostics:
CBC with PC
Urinalysis
Chest Xray
Sodium, Potassium
BUN, Creatinine

Medications:
Paracetamol 500mg/tab q4 prn for fever
Loratadine 10mg/tab OD
Metoclopramide 10mg/IV q8 prn for vomiting
Omeprazole 40mg/IV OD
Ceftriaxone 2g/IV OD ( ) ANST
Azithromycin 500mg/tab OD
Salbutamol + Ipratropium Bromide neb q8
Vital signs every 4 hours

Input and output every shift


Airborne precaution

Laboratory Findings

CBC

12/15/13

Erythrocytes

5.27

Hemoglobin

168.2

Hematocrit

0.465

Leukocyte

6.34

Neutrophil

0.655

Eosinophil

0.005

Basophils

0.047

Lymphocytes 0.158
Monocytes

0.047

Thrombocytes

132

MCH

31.93

MCV

31.93

MCHC

0.36

RDW

111

MPV

Blood typing

O positive

U/A

Color Speci pH
fic
Gravi
ty

Suga
r

Albu
min

Pus
Cells

RBC

Amo
rp
Urat
es

Amb
er

(-)

(-)

2-4

1-2

Mode Few
rate

1.025 6

Epith
cells

Bacte
ria

Few

Blood Chemistry

12/15/13

Sodium

121

Potassium

3.06

BUN

11.5

Creatinine

94.8

Chest Xray

Basal
Pneumonia,
Left

Course in the wards


1st Hospital Day
S: (+) cough

Potasium: 3.06

O: afebrile ; stable vital signs


A: Measles: Community Acquired Pneumonia
P: Continue present management
Start Kalium Durule TID for 2 days

2nd Hospital Day


S: decreased severity of cough
O: stable vital signs; decreased crackles
A: Measles; Community Acquired Pneumonia
P: Continue present management

3rd Hospital Day


S: no subjective complaints
O: afebrile
A: Measles; Community Acquired Pneumonia
P: May go home

Home Meds:
Cefixime 200mg/tab BID x 7days
Azithromycin 500mg/tabs OD x 3 days
Salbutamol + Ipratropium Bromide neb every 8 hours
Loratadine 10mg/tab OD as needed

Measles

Definition
highly contagious viral disease that is characterized

by a prodromal illness of fever, cough, coryza, and


conjunctivitis followed by the appearance of a
generalized maculopapular rash
The Centers for Disease Control and Prevention :(1)
a generalized maculopapular rash of at least 3 days'
duration; (2) fever of at least 38.3oC (101oF); and (3)
cough, coryza, or conjunctivitis.

Etiology
spherical, nonsegmented, single-stranded, negative-

sense RNA virus


Morbillivirus
family of Paramyxoviridae
antigenically monotypic virus

Epidemiology
most highly contagious directly transmitted

pathogens
common among household contacts, school-age
children, and health care workers
Endemic measles has a typical temporal pattern.
As measles vaccine coverage increases or population
density decreases
Persons with measles are infectious for several days
before and after the onset of rash.

Pathophysiology
Transmission
Respiratory droplets
Small-particle aerosols
Airborne transmission
Direct contact with infected secretions
Incubation Period
10 days to fever onset
14 days to rash onset
Adults up to 3 weeks

Clinical Manifestations

Kopliks spots
pathognomonic of

measles
bluish white dots 1 mm in
diameter surrounded by
erythema
buccal mucosa opposite
the lower molars but
rapidly increase in
number to involve the
entire buccal mucosa

Rash
erythematous macules

extremities
behind the ears and on petechiae may be present
the neck and hairline
The rash fades slowly progresses to involve the usually beginning on the
face, trunk, and arms
third or fourth day after
with involvement of the
onset
legs and feet by the end Resolution of the rash
of the second day
may be followed by
Areas of confluent rash
desquamation
appear on the trunk and

Differential Diagnosis
Rubella

Kawasaki disease
Infectious mononucleosis
Roseola

Scarlet fever
Rocky Mountain spotted fever
Enterovirus

Adenovirus infection
Drug sensitivity

Laboratory Diagnosis
Serology

Culture
PCR

Treatment
No specific antiviral

therapy
Supportive measures

Hydration
Antipyretic therapy
Antibiotic therapy
Pneumonia; Otitis Media

Vitamin A
>12 months of age - oncedaily doses of 200,000 IU of
vitamin A for 2 consecutive
days
6-12 months of age -100,000
IU per day
<6 months of age - 50,000
IU per day
third dose is recommended
24 weeks later for children
with evidence of vitamin A
deficiency

Complications
Most common
Otitis Media
Bronchopneumonia
Respiratory Tract
Acute laryngotracheobronchitis
Giant-cell pneumonitis
Central Nervous System
Encephalomyelitis
Measles inclusion body encephalitis
Subacute sclerosing panencephalitis

Prevention
Passive Immunization
Human immunoglobulin
within 72 h of exposure - immunocompetent persons
Administered up to 6 days after exposure
Prophylaxis - children <1 year of age, immunocompromised
persons and pregnant women
0.25 mL/kg given intramuscularly
Immunocompromised - 0.5 mL/kg.
maximum total dose - 15 mL
IV immunoglobulin usual dose of 100400 mg/kg
prophylaxis for measles exposures occurring as long as 3 weeks
or more after IV immunoglobulin administration

Active Immunization
Mumps and rubella (MMR)
Mumps, rubella, and varicella (MMR-V)
first vaccination varies from 6 to 15 months

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